Pneumothorax and air-leak syndromes — OSCE

Station brief (candidate)

• Assess this adolescent for tension pneumothorax before anything else and state how you would act if it were present.
• Confirm and size the pneumothorax and outline a management plan appropriate to a stable primary spontaneous pneumothorax.
• Explain the diagnosis to the anxious parent in plain language and agree follow-up and recurrence advice. [2] [5]

Role-player notes

You are the parent of a healthy 15-year-old who suddenly developed chest pain and breathlessness while sitting in class. You are frightened because he "couldn't breathe properly" and you want to know whether it is his heart, whether he needs an operation, and whether it will happen again. You settle when the doctor examines him promptly, checks he is not deteriorating, explains what a collapsed lung is in simple terms, and gives a clear plan and warning signs. You become distressed if the doctor uses jargon, dismisses your worry, or cannot say whether it might recur. [11]

Expected candidate performance

1. Tension check first: State immediately that the priority is to exclude tension — hypotension, tracheal deviation, distended neck veins, unilateral absent breath sounds — and that a tension pneumothorax would be decompressed at once without waiting for imaging. [2]
2. Structured assessment: Take a focused history (onset, previous episodes, smoking and vaping, lung disease, connective-tissue features) and examine for reduced expansion, hyper-resonance and reduced breath sounds. [5]
3. Confirm and size: Order an erect chest radiograph to confirm and size the leak, using the rim of air at the hilum, and mention point-of-care lung ultrasound as a bedside adjunct. [9]
4. Management: For a small, stable, minimally symptomatic primary pneumothorax, give oxygen and observe; for a larger or symptomatic leak, use needle aspiration or a small-bore drain, escalating as needed. [1]
5. Follow-up and recurrence: Explain that same-side recurrence is common and that surgery is considered after recurrence, and arrange respiratory follow-up. [11]
6. Communication: Explain a collapsed lung simply, validate the parent's fear, and agree smoking, vaping, diving and flying advice with teach-back. [5]

Marking domains

• Tension excluded and prioritised before imaging.
• Focused history and examination for pneumothorax and its causes.
• Appropriate confirmation, sizing and a management plan matched to a stable primary leak.
• Clear recurrence and lifestyle advice with follow-up.
• Jargon-free, concern-validating communication with the parent. [2] [5]

Common fails

• Ordering imaging before excluding or treating tension in a deteriorating child. [2]
• Draining a small, stable, primary pneumothorax that could be observed. [1]
• Forgetting smoking, vaping, diving and flying advice, and the high recurrence risk. [11]
• Failing to consider underlying lung or connective-tissue disease after a first leak. [5]